Healthcare Provider Details

I. General information

NPI: 1396955316
Provider Name (Legal Business Name): SUSAN J MACK RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 STACY BURK DRIVE
FLORA IL
62839
US

IV. Provider business mailing address

608 N MAIN ST
FLORA IL
62839-1406
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-2191
  • Fax:
Mailing address:
  • Phone: 618-662-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number070430
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007907
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: